| NPI | 1699181172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: PA OT021469) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056958) |
| Enumeration Date | 2014-07-07 |
| Last Update Date | 2023-08-02 |