| NPI | 1932591963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA179272) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 3350) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-02-27 |
| Last Update Date | 2020-04-22 |