| NPI | 1306800644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 58601) |
| Enumeration Date | 2006-04-13 |
| Last Update Date | 2022-09-22 |