| NPI | 1487023248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2058) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA3108) |
| Enumeration Date | 2015-09-22 |
| Last Update Date | 2022-05-10 |