| NPI | 1871668525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA813) |
| Additional Taxonomies | 208800000X Urology (Licence: KY PA813) |
| 363A00000X Physician Assistant (Licence: KY PA813) | |
| 363A00000X Physician Assistant (Licence: IL 085-001922) | |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2020-12-04 |