| NPI | 1245559749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2093) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC947) |
| Enumeration Date | 2010-05-24 |
| Last Update Date | 2017-05-22 |