| NPI | 1366976136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA183778) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA 1510077) |
| Enumeration Date | 2017-04-18 |
| Last Update Date | 2019-11-19 |