| NPI | 1568467686 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY PA834) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IN 10000605A) |
| Enumeration Date | 2005-06-15 |
| Last Update Date | 2013-07-08 |