| NPI | 1447897988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8115) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 026575) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-12-03 |
| Last Update Date | 2024-06-25 |