| NPI | 1992553226 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110011776) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 878) |
| Enumeration Date | 2024-05-10 |
| Last Update Date | 2026-05-11 |