| NPI | 1417914789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0116035964) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110001910) |
| Enumeration Date | 2006-04-28 |
| Last Update Date | 2021-07-08 |