| NPI | 1750637740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-03549) |
| Enumeration Date | 2012-07-27 |
| Last Update Date | 2021-04-26 |