| NPI | 1609958941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 00954) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50001706) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2007-07-27 |