| NPI | 1285296137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1285296137) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: 1285296137) |
| Enumeration Date | 2019-07-01 |
| Last Update Date | 2024-09-11 |