| 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 |