| NPI | 1801005004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 01099) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0003043) |
| 363A00000X Physician Assistant (Licence: VA 0110001870) | |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2007-07-08 |