| NPI | 1922562818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AL 1730) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-007207) |
| 363A00000X Physician Assistant (Licence: TN 4650) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-01-25 |
| Last Update Date | 2021-07-30 |