| NPI | 1366762205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MI 5601008189) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MI 5201007729) |
| Enumeration Date | 2010-06-02 |
| Last Update Date | 2025-12-05 |