NPI | 1316210040 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA1714) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA1714) |
Enumeration Date | 2012-02-10 |
Last Update Date | 2019-03-05 |