| NPI | 1376702654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY KY PA 837) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA 837) |
| Enumeration Date | 2008-06-03 |
| Last Update Date | 2015-03-27 |