| NPI | 1134123466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA 258) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY PA258) |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2020-12-03 |