| NPI | 1174238315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: IN 10004430A) | |
| Enumeration Date | 2023-01-23 |
| Last Update Date | 2024-07-02 |