| NPI | 1629685912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: NC 0010-11302) |
| 363A00000X Physician Assistant (Licence: NC 0010-11302) | |
| 363AS0400X Physician Assistant Surgical (Licence: NC 0010-11302) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-09-30 |
| Last Update Date | 2023-12-01 |