| NPI | 1023365715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1705) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 100752) |
| Enumeration Date | 2012-08-13 |
| Last Update Date | 2015-05-12 |