| NPI | 1659349405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 306) |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2016-06-02 |