| NPI | 1881977916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05173) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 01579) |
| Enumeration Date | 2011-09-26 |
| Last Update Date | 2014-12-10 |