| NPI | 1598826299 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1882) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002429) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2023-11-30 |