| NPI | 1407383318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PR 873) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PR 17307-I) |
| Enumeration Date | 2017-05-23 |
| Last Update Date | 2025-01-21 |