| NPI | 1598248478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113128) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-09-07 |
| Last Update Date | 2023-09-12 |