| NPI | 1700474046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8546) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA8546) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-01-04 |
| Last Update Date | 2023-08-11 |