| NPI | 1053655464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| Enumeration Date | 2012-11-26 |
| Last Update Date | 2022-03-06 |