| NPI | 1548871387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: 390200000X) |
| Enumeration Date | 2020-08-14 |
| Last Update Date | 2023-04-05 |