| NPI | 1558121392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-14935) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2024-03-20 |
| Last Update Date | 2025-01-22 |