| NPI | 1699383521 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2694) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KY PA2694) |
| 363AM0700X Physician Assistant, Medical (Licence: KY PA2694) | |
| Enumeration Date | 2020-07-16 |
| Last Update Date | 2025-10-24 |