| NPI | 1568492023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002922) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA762) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2019-02-08 |