| NPI | 1922748474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5070) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC151) |
| Enumeration Date | 2022-03-31 |
| Last Update Date | 2025-11-14 |