| NPI | 1184093502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| 363AS0400X Physician Assistant Surgical | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-09-15 |
| Last Update Date | 2025-07-05 |