| NPI | 1174804124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: VA 0102206873) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 363A00000X Physician Assistant (Licence: MA PA4789) | |
| 363AM0700X Physician Assistant, Medical | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-09-05 |
| Last Update Date | 2023-08-07 |