| NPI | 1508258856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 700) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC366) |
| 363A00000X Physician Assistant (Licence: KY PA1983) | |
| 363A00000X Physician Assistant (Licence: OH 50.004709RX) | |
| 363A00000X Physician Assistant (Licence: SC 2775) | |
| Enumeration Date | 2015-02-24 |
| Last Update Date | 2021-01-28 |