| NPI | 1134200223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA071) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN PA0000000153) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2016-05-25 |