| NPI | 1598219412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2121) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC497) |
| Enumeration Date | 2016-08-09 |
| Last Update Date | 2020-12-09 |