| NPI | 1962910026 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: AL PA.1524) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WV 2149) |
| Enumeration Date | 2018-01-10 |
| Last Update Date | 2020-02-06 |