| NPI | 1467894089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA1804) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA1804) |
| 363AM0700X Physician Assistant, Medical (Licence: KY TC208) | |
| Enumeration Date | 2013-07-24 |
| Last Update Date | 2020-12-08 |