| NPI | 1386919694 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1742) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: KY PA1742) |
| 363AS0400X Physician Assistant Surgical (Licence: KY PA1742) | |
| Enumeration Date | 2012-03-20 |
| Last Update Date | 2021-05-05 |