| NPI | 1801363577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2428) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363A00000X Physician Assistant (Licence: UT 11240954-1206) | |
| Enumeration Date | 2018-10-31 |
| Last Update Date | 2023-08-22 |