| NPI | 1770356370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IN 10005273A) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA3419) |
| Enumeration Date | 2023-11-06 |
| Last Update Date | 2026-04-02 |