| NPI | 1023384401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2012-03-29 |
| Last Update Date | 2021-09-21 |