| NPI | 1194587824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 7871497) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC075) |
| Enumeration Date | 2024-01-29 |
| Last Update Date | 2026-06-09 |