NPI | 1114654027 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: UT 9374356-1206) |
Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
Enumeration Date | 2022-08-02 |
Last Update Date | 2024-06-19 |