| NPI | 1518627173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14870) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-12-23 |
| Last Update Date | 2026-07-02 |