| NPI | 1811972409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY PA767) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 1988) |
| Enumeration Date | 2005-12-07 |
| Last Update Date | 2024-02-20 |