| NPI | 1497393946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA064585) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA2543) |
| 363A00000X Physician Assistant (Licence: PA OA006437) | |
| Enumeration Date | 2019-12-16 |
| Last Update Date | 2023-10-20 |