| NPI | 1366468605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA359) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: KY PA359) |
| 363AS0400X Physician Assistant Surgical (Licence: KY PA359) | |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2024-09-27 |