| NPI | 1710467220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MO 1158133) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-08-15 |
| Last Update Date | 2022-04-27 |