| NPI | 1801082730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07923) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-07923) |
| 363AM0700X Physician Assistant, Medical (Licence: WV 01295) | |
| Enumeration Date | 2007-09-25 |
| Last Update Date | 2023-09-19 |