| NPI | 1245609106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2102) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 1080) |
| Enumeration Date | 2015-09-22 |
| Last Update Date | 2019-09-17 |