| NPI | 1962153783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA8364) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 030074) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-01-13 |
| Last Update Date | 2024-09-27 |