| NPI | 1922463918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2424) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50 004628RX) |
| 363A00000X Physician Assistant (Licence: KY TC752) | |
| Enumeration Date | 2015-12-18 |
| Last Update Date | 2021-10-26 |