| NPI | 1770356370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: KY PA3419) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-11-06 |
| Last Update Date | 2024-09-13 |