| NPI | 1578058194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13001) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-06-26 |
| Last Update Date | 2024-05-14 |