| NPI | 1801331186 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0006400) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2152) |
| Enumeration Date | 2016-12-22 |
| Last Update Date | 2021-05-15 |