| NPI | 1023671567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA 312682) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA12909) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-19 |
| Last Update Date | 2021-10-20 |