| NPI | 1649859703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 2705) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 026452-01) |
| 363A00000X Physician Assistant (Licence: WV 2705) | |
| Enumeration Date | 2021-04-06 |
| Last Update Date | 2023-07-24 |