| NPI | 1568465771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 2256) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0002450) |
| 363A00000X Physician Assistant (Licence: VA 0110007496) | |
| Enumeration Date | 2005-05-23 |
| Last Update Date | 2021-03-08 |