| NPI | 1336789767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-01-14 |
| Last Update Date | 2023-10-11 |