| NPI | 1063153492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3071) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KY TC320) |
| Enumeration Date | 2022-04-07 |
| Last Update Date | 2023-10-16 |