| NPI | 1740929637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC PA5218) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA9256) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-05-31 |
| Last Update Date | 2024-10-09 |