| NPI | 1053354068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1008) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1227) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2024-02-22 |