| NPI | 1104442342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC964) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical (Licence: KY TC964) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KY TC964) | |
| Enumeration Date | 2020-06-23 |
| Last Update Date | 2020-09-10 |