| NPI | 1225511504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT MED-PAC-LIC-69671) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-69671) | |
| Enumeration Date | 2018-09-12 |
| Last Update Date | 2021-12-14 |