| NPI | 1780617837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08351) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WV 01122) |
| Enumeration Date | 2006-07-09 |
| Last Update Date | 2020-09-11 |