NPI | 1407304637 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2452) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.004796RX) |
Enumeration Date | 2016-09-16 |
Last Update Date | 2019-04-30 |