| NPI | 1497742670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY PA 337) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085002225) |
| 363AM0700X Physician Assistant, Medical (Licence: KY PA337) | |
| Enumeration Date | 2005-10-03 |
| Last Update Date | 2015-06-08 |