| NPI | 1285212639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA95352) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 5263) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-29 |
| Last Update Date | 2023-11-10 |