| NPI | 1457830580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2387) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY PA2387) |
| 363A00000X Physician Assistant (Licence: KY TC724) | |
| Enumeration Date | 2018-08-09 |
| Last Update Date | 2021-05-05 |