| NPI | 1871308700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9120343) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2025-02-10 |
| Last Update Date | 2026-01-15 |