| NPI | 1174757900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1195) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC016) |
| Enumeration Date | 2009-05-07 |
| Last Update Date | 2015-03-10 |