| NPI | 1144241472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 1058) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA702) |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2012-08-14 |