| NPI | 1598062879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 1872) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-02659) |
| Enumeration Date | 2011-02-22 |
| Last Update Date | 2023-11-27 |