| NPI | 1104255124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA056599) |
| Enumeration Date | 2013-11-12 |
| Last Update Date | 2019-03-22 |