| NPI | 1740263995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 582) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC A956) |
| Enumeration Date | 2005-11-22 |
| Last Update Date | 2019-04-18 |