| NPI | 1972535367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WV 690) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WV 00690) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2023-11-09 |