| NPI | 1639785470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2020026547) |
| Enumeration Date | 2020-09-17 |
| Last Update Date | 2023-03-21 |