| NPI | 1205162252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1219) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA1219) |
| 363AS0400X Physician Assistant, Surgical (Licence: KY PA1219) | |
| Enumeration Date | 2009-10-27 |
| Last Update Date | 2020-05-29 |