| NPI | 1639530199 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 1133017) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY 1133017) |
| Enumeration Date | 2016-03-11 |
| Last Update Date | 2024-01-10 |