| NPI | 1902205438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL 65545) |
| Enumeration Date | 2014-08-20 |
| Last Update Date | 2020-02-17 |