| NPI | 1972751808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 1730) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002878) |
| Enumeration Date | 2008-09-04 |
| Last Update Date | 2016-01-08 |