| NPI | 1457974453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2947) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: IN 10003015A) | |
| Enumeration Date | 2020-05-26 |
| Last Update Date | 2023-05-19 |