| NPI | 1336561901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2011) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 2487) |
| Enumeration Date | 2014-01-15 |
| Last Update Date | 2023-12-19 |