| NPI | 1669563128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 1948) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA052513) |
| Enumeration Date | 2006-09-27 |
| Last Update Date | 2024-09-20 |