| NPI | 1386408995 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA067100) | 
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program | 
| Enumeration Date | 2024-02-13 | 
| Last Update Date | 2025-09-23 |