| NPI | 1114630019 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2023-01-05 |
| Last Update Date | 2024-07-05 |