| NPI | 1235771239 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MS PA00597) |
| Enumeration Date | 2019-10-10 |
| Last Update Date | 2021-10-05 |