| NPI | 1336626910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2022015422) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.006784) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-07-26 |
| Last Update Date | 2024-11-12 |