| NPI | 1518147842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1042) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA0000001594) |
| Enumeration Date | 2007-11-03 |
| Last Update Date | 2016-03-11 |