| NPI | 1649692765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2765) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC028) |
| 363A00000X Physician Assistant (Licence: WV 01781) | |
| 363A00000X Physician Assistant (Licence: VA 0110007036) | |
| Enumeration Date | 2014-01-08 |
| Last Update Date | 2024-09-17 |