| NPI | 1679235683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9790) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-2771) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-10-07 |
| Last Update Date | 2025-03-30 |