| NPI | 1902265317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-2499) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-02-12 |
| Last Update Date | 2023-06-06 |