| NPI | 1306396486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2132) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC545) |
| Enumeration Date | 2016-10-12 |
| Last Update Date | 2023-12-07 |