| NPI | 1033697990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2449) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.005673) |
| Enumeration Date | 2018-08-02 |
| Last Update Date | 2022-05-24 |