| NPI | 1740663608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC110) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: KY TC110) |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 2796) | |
| 363A00000X Physician Assistant (Licence: TN 2796) | |
| 363A00000X Physician Assistant (Licence: IN 10003888A) | |
| 363AM0700X Physician Assistant, Medical (Licence: KY TC110) | |
| 363AM0700X Physician Assistant, Medical (Licence: TN 2796) | |
| Enumeration Date | 2015-07-09 |
| Last Update Date | 2024-12-19 |