| NPI | 1003549452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3272) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: KY TC006) | |
| 363AM0700X Physician Assistant Medical (Licence: KY TC006) | |
| 363AM0700X Physician Assistant Medical (Licence: KY PA3272) | |
| 363AS0400X Physician Assistant Surgical (Licence: KY TC006) | |
| 363AS0400X Physician Assistant Surgical (Licence: KY PA3272) | |
| Enumeration Date | 2022-07-05 |
| Last Update Date | 2024-01-10 |