| NPI | 1699105304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2372) |
| Additional Taxonomies | 225X00000X Occupational Therapist (Licence: WV 1630) |
| 363A00000X Physician Assistant (Licence: OH 50.006077RX) | |
| 363A00000X Physician Assistant (Licence: WV 2096) | |
| 363A00000X Physician Assistant (Licence: KY TC717) | |
| Enumeration Date | 2013-11-15 |
| Last Update Date | 2025-12-22 |