| NPI | 1871131359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA005403) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-12-16 |
| Last Update Date | 2022-01-12 |