| NPI | 1942689864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: NC 2025-04024) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-05-26 |
| Last Update Date | 2026-04-15 |