| NPI | 1144507237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA57011) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 1710I1002X Military Health Care Provider, Independent Duty Corpsman | |
| Enumeration Date | 2011-11-03 |
| Last Update Date | 2019-07-12 |