| NPI | 1235513540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-07-16 |
| Last Update Date | 2025-05-09 |