| NPI | 1518440411 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11056) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-09-07 |
| Last Update Date | 2023-08-10 |