| NPI | 1396214748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY PA3697) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08368) |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10003985A) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KY TC048) | |
| Enumeration Date | 2018-11-15 |
| Last Update Date | 2025-09-22 |