| NPI | 1972570596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: KY PA773) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA773) |
| 363AM0700X Physician Assistant, Medical (Licence: MT 34998) | |
| Enumeration Date | 2006-03-02 |
| Last Update Date | 2024-07-18 |