| NPI | 1811136799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY 1441) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA1441) |
| 363A00000X Physician Assistant (Licence: KY PA1441) | |
| Enumeration Date | 2009-02-17 |
| Last Update Date | 2026-07-31 |