| NPI | 1336249465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic |
| 1710I1002X Military Health Care Provider, Independent Duty Corpsman | |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2010-05-21 |