| NPI | 1740039940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC059) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KY TC059) |
| 363AM0700X Physician Assistant, Medical (Licence: KY TC059) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2024-05-18 |
| Last Update Date | 2024-10-03 |