| NPI | 1295214047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2393) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC729) |
| Enumeration Date | 2018-08-13 |
| Last Update Date | 2024-04-12 |