| NPI | 1679584569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: VA 0110-840765) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WV 01340) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2021-09-15 |