| NPI | 1811907785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA148) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: KY PA148) |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2008-04-15 |