| NPI | 1750560801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC819) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10001647A) |
| Enumeration Date | 2007-10-25 |
| Last Update Date | 2019-07-01 |