| NPI | 1255868063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA058752) |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2024-03-28 |