| NPI | 1922401082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: KY TC325) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2014-10-03 |
| Last Update Date | 2016-05-04 |