| NPI | 1629546239 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601009597) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-13513) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-11-13 |
| Last Update Date | 2025-03-04 |