| NPI | 1306020359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WA 60118135) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2007-12-27 |
| Last Update Date | 2024-09-24 |