| NPI | 1700139045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WV 1885) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA055816) |
| Enumeration Date | 2012-10-24 |
| Last Update Date | 2022-04-05 |