| NPI | 1760702039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-05376) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA1554) |
| Enumeration Date | 2010-06-09 |
| Last Update Date | 2023-07-17 |