| NPI | 1619374246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1954) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY TC337) |
| Enumeration Date | 2014-11-25 |
| Last Update Date | 2018-09-07 |