| NPI | 1568936532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11950) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2019-01-14 |
| Last Update Date | 2024-11-06 |