| NPI | 1942709696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110006095) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 2277) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2018-02-08 |
| Last Update Date | 2021-11-01 |