| NPI | 1811364250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2018) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC415) |
| Enumeration Date | 2015-09-01 |
| Last Update Date | 2021-08-30 |