| NPI | 1639927759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.008931RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC028) |
| Enumeration Date | 2024-05-13 |
| Last Update Date | 2024-08-28 |