| NPI | 1013635523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 2865M2000X Military Hospital, Military General Acute Care Hospital | |
| Enumeration Date | 2022-08-19 |
| Last Update Date | 2023-03-15 |