| NPI | 1710238126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 5164) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: AZ 5164) |
| Enumeration Date | 2012-09-25 |
| Last Update Date | 2014-02-18 |