| NPI | 1588746622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: KY 1473P) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA105) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2013-05-10 |