| NPI | 1124067251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA170) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0004436) |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2023-08-29 |