| NPI | 1386261089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2663) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC934) |
| Enumeration Date | 2020-06-29 |
| Last Update Date | 2023-04-26 |