| NPI | 1801830955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2084) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 869) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2016-04-18 |