| NPI | 1174890172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1689) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA1689) |
| 363AS0400X Physician Assistant, Surgical (Licence: KY PA1689) | |
| Enumeration Date | 2011-11-19 |
| Last Update Date | 2023-10-16 |