| NPI | 1922386804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY TC030) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA1679) |
| Enumeration Date | 2011-07-27 |
| Last Update Date | 2022-07-21 |