| 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 |