| NPI | 1659929859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2592) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC865) |
| 363A00000X Physician Assistant (Licence: Pending) | |
| Enumeration Date | 2019-08-30 |
| Last Update Date | 2021-01-28 |