| NPI | 1659751709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9111471) |
| Additional Taxonomies | 172V00000X Community Health Worker (Licence: KY AT1206) |
| Enumeration Date | 2015-06-04 |
| Last Update Date | 2019-02-26 |