| NPI | 1306268008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4842) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY 1115651) |
| Enumeration Date | 2014-01-14 |
| Last Update Date | 2024-10-01 |