| NPI | 1962156901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3093) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC255) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-02-08 |
| Last Update Date | 2023-03-08 |