| NPI | 1871009589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07754) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-12-18 |
| Last Update Date | 2025-04-09 |