| NPI | 1588386759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3082) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC308) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2022-09-14 |
| Last Update Date | 2023-03-01 |