| NPI | 1972117265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA2874) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC105) |
| 363AM0700X Physician Assistant, Medical (Licence: KY TC105) | |
| 363AM0700X Physician Assistant, Medical (Licence: KY PA2874) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KY TC105) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KY PA2874) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-09-03 |
| Last Update Date | 2022-01-27 |