| NPI | 1831572569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY PA2175) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA2175) |
| 363A00000X Physician Assistant (Licence: MD C05863) | |
| 363AM0700X Physician Assistant, Medical (Licence: KY PA2175) | |
| Enumeration Date | 2015-06-30 |
| Last Update Date | 2024-05-13 |