| NPI | 1700165008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OH 50.003681RX) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA1668) |
| Enumeration Date | 2011-08-04 |
| Last Update Date | 2021-05-12 |