| NPI | 1750931127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3007) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA62937) |
| Enumeration Date | 2019-09-17 |
| Last Update Date | 2024-03-04 |