| NPI | 1598394991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2687) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC985) |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2021-01-04 |