| NPI | 1720638547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VT 055-0031586) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61115512) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-09-13 |
| Last Update Date | 2022-09-08 |