| NPI | 1518222728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2250) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KY TC120) |
| Enumeration Date | 2012-07-13 |
| Last Update Date | 2014-12-16 |