| NPI | 1285872457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61120848) |
| Enumeration Date | 2009-01-27 |
| Last Update Date | 2021-08-26 |