| NPI | 1700062072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 10210150-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 4395) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: AZ T686) | |
| Enumeration Date | 2008-01-16 |
| Last Update Date | 2017-04-25 |