| NPI | 1720021447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110840810) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 762) |
| Enumeration Date | 2006-06-13 |
| Last Update Date | 2024-04-05 |