| NPI | 1801490081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 0008198) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: NY 028608) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-11-28 |
| Last Update Date | 2024-05-02 |