| NPI | 1285654517 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 1693) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA606) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2021-11-18 |