| NPI | 1598149346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC923) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 4775) |
| 363A00000X Physician Assistant (Licence: HI AMD 629) | |
| Enumeration Date | 2015-07-10 |
| Last Update Date | 2020-10-29 |