| NPI | 1962871871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2015) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601011131) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 56283) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CA 56283) | |
| Enumeration Date | 2015-09-21 |
| Last Update Date | 2022-06-27 |