| NPI | 1780112557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WV 778) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 778) |
| Enumeration Date | 2017-05-24 |
| Last Update Date | 2021-12-23 |