| NPI | 1225601446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2794) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: KY PA2794) |
| Enumeration Date | 2021-07-24 |
| Last Update Date | 2023-05-24 |