| NPI | 1922006006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 482) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: WV 00482) |
| 363A00000X Physician Assistant (Licence: VA 0110840604) | |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2021-11-18 |