| NPI | 1023724465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13079175-1206) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: UT 13079175-1206) |
| Enumeration Date | 2023-01-30 |
| Last Update Date | 2024-12-12 |