| NPI | 1528732062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12455920-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 12455920-1206) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-08-08 |
| Last Update Date | 2024-10-14 |