| NPI | 1467028522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2823) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC049) |
| Enumeration Date | 2021-05-31 |
| Last Update Date | 2022-03-30 |