| NPI | 1154895423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-09858) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3788) |
| 207QA0505X Family Medicine, Adult Medicine (Licence: NC 0010-09858) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-01-19 |
| Last Update Date | 2021-01-28 |