| NPI | 1104468966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12804) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: PA MA06250) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-10-14 |
| Last Update Date | 2024-07-19 |