| NPI | 1205815560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 133V00000X Dietitian, Registered (Licence: KY KY1531) |
| Enumeration Date | 2006-01-13 |
| Last Update Date | 2008-12-17 |