| NPI | 1871687707 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1388) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KY PA335) |
| 363AM0700X Physician Assistant, Medical (Licence: SC 1388) | |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2025-03-03 |