| NPI | 1275738197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC020) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 99027503A) |
| Enumeration Date | 2007-06-20 |
| Last Update Date | 2013-07-08 |