| NPI | 1851850762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY TC379) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.005730RX) |
| Enumeration Date | 2019-03-19 |
| Last Update Date | 2023-08-07 |