| NPI | 1154135648 |
|---|---|
| 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: WI 8417) |
| Enumeration Date | 2025-02-04 |
| Last Update Date | 2025-09-05 |