| NPI | 1184136780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060759) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA004881) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-11-04 |
| Last Update Date | 2019-08-05 |