| NPI | 1043616873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CT 003197) |
| Enumeration Date | 2014-11-05 |
| Last Update Date | 2025-04-16 |