| NPI | 1568936532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-11950) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-11950) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2019-01-14 |
| Last Update Date | 2025-10-03 |