| NPI | 1285991216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 57424) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 363A00000X Physician Assistant (Licence: NV PA1891) | |
| Enumeration Date | 2012-04-16 |
| Last Update Date | 2025-08-21 |