| NPI | 1114255486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1795) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 99080994A) |
| Enumeration Date | 2009-11-25 |
| Last Update Date | 2020-12-07 |