| NPI | 1851046403 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 5598) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC284) |
| 363AM0700X Physician Assistant Medical (Licence: KY TC284) | |
| 363AS0400X Physician Assistant Surgical (Licence: KY TC284) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-02-12 |
| Last Update Date | 2023-08-16 |