| NPI | 1790788180 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA682) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2021-05-12 |