| NPI | 1801521661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-147324) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 363A00000X Physician Assistant (Licence: NM PA2023-0315) | |
| Enumeration Date | 2022-07-17 |
| Last Update Date | 2025-10-08 |