| NPI | 1285983247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1161440) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| 363A00000X Physician Assistant (Licence: NC 0010-11081) | |
| Enumeration Date | 2012-09-06 |
| Last Update Date | 2021-10-05 |