NPI | 1689045130 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2020) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA2020) |
363AS0400X Physician Assistant, Surgical (Licence: KY PA2020) | |
Enumeration Date | 2015-10-09 |
Last Update Date | 2020-08-17 |