| NPI | 1699050617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NE 8916) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY 532) |
| Enumeration Date | 2011-10-21 |
| Last Update Date | 2020-06-26 |