| NPI | 1154998540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2916) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 5318) |
| Enumeration Date | 2021-06-05 |
| Last Update Date | 2023-05-09 |