| NPI | 1750072864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9117601) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9117601) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-05-18 |
| Last Update Date | 2023-09-15 |