| NPI | 1154075950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3083) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC281) |
| Enumeration Date | 2022-02-09 |
| Last Update Date | 2023-03-29 |