| NPI | 1720312861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 699) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 931) |
| Enumeration Date | 2009-09-22 |
| Last Update Date | 2021-12-15 |