| NPI | 1548990955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2022-06-16 |
| Last Update Date | 2024-05-21 |