| NPI | 1063938025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 8471) |
| 363A00000X Physician Assistant (Licence: KS 15-02062) | |
| Enumeration Date | 2017-08-21 |
| Last Update Date | 2023-03-29 |