| NPI | 1174171433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8501) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 004634) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-08-29 |
| Last Update Date | 2023-06-09 |