| NPI | 1285947952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2010-07-22 |
| Last Update Date | 2019-08-06 |