| NPI | 1811352685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2746) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KY AT1319) |
| 363A00000X Physician Assistant (Licence: AT1319) | |
| Enumeration Date | 2015-12-22 |
| Last Update Date | 2021-10-29 |