| NPI | 1457911471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-06-20 |
| Last Update Date | 2024-07-09 |