| NPI | 1922624766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 027765) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VT 055.0031591) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-06-17 |
| Last Update Date | 2025-06-02 |