| NPI | 1649643982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 1955) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004527) |
| Enumeration Date | 2015-11-09 |
| Last Update Date | 2015-11-09 |