| NPI | 1972891927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA1988) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-004241) |
| 363A00000X Physician Assistant (Licence: KY TC363) | |
| Enumeration Date | 2011-07-12 |
| Last Update Date | 2022-07-21 |