| NPI | 1174363048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC066) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KY TC066) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| 363AM0700X Physician Assistant, Medical (Licence: KY TC066) | |
| Enumeration Date | 2024-05-29 |
| Last Update Date | 2026-08-20 |