| NPI | 1821193525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA660) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA0000000899) |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2021-06-07 |