| NPI | 1154766152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 6005) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA1769) |
| 363AM0700X Physician Assistant Medical (Licence: KY PA1769) | |
| Enumeration Date | 2013-05-03 |
| Last Update Date | 2024-09-11 |