| NPI | 1548972375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110009506) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-12-26 |
| Last Update Date | 2024-02-08 |