| NPI | 1801173125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MA PA5942) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: KY TC068) |
| Enumeration Date | 2011-11-15 |
| Last Update Date | 2016-12-01 |