| NPI | 1033885413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2901) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: NY 026004) | |
| 363AM0700X Physician Assistant Medical (Licence: KY PA2901) | |
| 363AS0400X Physician Assistant Surgical (Licence: KY PA2901) | |
| Enumeration Date | 2021-08-17 |
| Last Update Date | 2023-06-01 |