| NPI | 1295118446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC699) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001845A) |
| Enumeration Date | 2015-07-07 |
| Last Update Date | 2018-04-23 |