| NPI | 1174251334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3132) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.007606RX) |
| Enumeration Date | 2022-08-15 |
| Last Update Date | 2023-03-23 |