| NPI | 1790188571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 2008) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA3036) |
| Enumeration Date | 2014-10-07 |
| Last Update Date | 2025-01-14 |