| NPI | 1164472882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA322) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA322) |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2026-08-13 |