| NPI | 1588737621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA974) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 1449) |
| Enumeration Date | 2006-11-16 |
| Last Update Date | 2019-05-03 |