| NPI | 1629631320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA004857) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA060676) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-17 |
| Last Update Date | 2021-04-15 |