| NPI | 1568818268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 3010) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA54441) |
| Enumeration Date | 2016-05-11 |
| Last Update Date | 2025-12-05 |