| NPI | 1093264459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06709) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 001006709) |
| Enumeration Date | 2016-09-27 |
| Last Update Date | 2023-07-10 |