| NPI | 1720335904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9105264) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY 1440) |
| Enumeration Date | 2012-08-07 |
| Last Update Date | 2021-09-15 |