| NPI | 1376571885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY KYPA925) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KY PA925) |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10000826A) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2022-08-09 |