| NPI | 1265998439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9243) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: GA PENDING) |
| Enumeration Date | 2019-02-13 |
| Last Update Date | 2019-09-25 |