| NPI | 1417563404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IL 085.010251) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 14271) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-09-16 |
| Last Update Date | 2024-12-20 |