| NPI | 1962815787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA1937) |
| Enumeration Date | 2014-06-09 |
| Last Update Date | 2020-09-03 |