| NPI | 1780641415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA1816) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 943) |
| 363AM0700X Physician Assistant, Medical (Licence: WV 00943) | |
| 363AM0700X Physician Assistant, Medical (Licence: OH 50.001490) | |
| Enumeration Date | 2006-04-27 |
| Last Update Date | 2018-04-19 |