| NPI | 1336592872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08781) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020147-1) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2021-04-02 |