| NPI | 1801462353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: IL 125079231) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2021019782) |
| Enumeration Date | 2021-06-03 |
| Last Update Date | 2022-06-20 |