| NPI | 1083278816 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NC 0010-13638) | 
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1169357) | 
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-26 | 
| Last Update Date | 2025-05-19 |