| NPI | 1619454980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1153418) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-07-19 |
| Last Update Date | 2021-04-14 |