| NPI | 1679812069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055958) |
| Enumeration Date | 2013-02-06 |
| Last Update Date | 2021-06-17 |