| NPI | 1053073361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC033) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-02557) |
| 363A00000X Physician Assistant (Licence: LA 328272) | |
| 363A00000X Physician Assistant (Licence: IN 10003412A) | |
| 363AM0700X Physician Assistant, Medical (Licence: KY TC033) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KY TC033) | |
| Enumeration Date | 2021-10-13 |
| Last Update Date | 2024-09-03 |