| NPI | 1912952193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 979) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 2474-23) |
| Enumeration Date | 2006-05-24 |
| Last Update Date | 2021-11-22 |