| NPI | 1497085633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2493) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: TN 4619) | |
| Enumeration Date | 2010-01-11 |
| Last Update Date | 2025-12-23 |