| NPI | 1528455425 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 60962) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| 171000000X Military Health Care Provider | |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2015-04-20 |
| Last Update Date | 2023-06-14 |