| NPI | 1861046328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 12849310-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA200320) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-08-01 |
| Last Update Date | 2022-06-24 |