| NPI | 1578551412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: OK 1051) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2021-03-26 |