| NPI | 1649469552 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1078) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA1078) |
| Enumeration Date | 2007-10-16 |
| Last Update Date | 2010-10-15 |