| NPI | 1639788326 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IN 10002987A) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA2736) |
| Enumeration Date | 2020-07-28 |
| Last Update Date | 2024-03-15 |