NPI | 1083317440 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3300) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC047) |
363AM0700X Physician Assistant, Medical (Licence: KY TC047) | |
363AM0700X Physician Assistant, Medical | |
363AM0700X Physician Assistant, Medical (Licence: KY PA3300) | |
363AS0400X Physician Assistant, Surgical (Licence: KY TC047) | |
363AS0400X Physician Assistant, Surgical (Licence: KY PA3300) | |
Enumeration Date | 2023-03-24 |
Last Update Date | 2024-01-10 |