| NPI | 1598702888 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AR PA-951) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.003668) |
| 363AS0400X Physician Assistant, Surgical (Licence: KY PA778) | |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2021-02-24 |