| NPI | 1588183909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY PA2768) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC037) |
| 363A00000X Physician Assistant (Licence: KY PA2768) | |
| Enumeration Date | 2017-09-18 |
| Last Update Date | 2025-12-12 |