| NPI | 1033438320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2818) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC059) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 3622) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 016600) | |
| Enumeration Date | 2010-05-26 |
| Last Update Date | 2022-01-25 |