| NPI | 1154069128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9238) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 9238) |
| 363AS0400X Physician Assistant Surgical (Licence: AZ 9238) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-05-20 |
| Last Update Date | 2022-08-24 |