| NPI | 1447240023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.004594RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA086) |
| 363A00000X Physician Assistant (Licence: TN 2527) | |
| 363AS0400X Physician Assistant Surgical (Licence: KY PA086) | |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2018-07-31 |