| NPI | 1457012908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC159) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2023009776) |
| Enumeration Date | 2022-01-06 |
| Last Update Date | 2024-06-18 |