| NPI | 1639129968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NC 0010-11776) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9104101) |
| 363A00000X Physician Assistant (Licence: NC 0010-11776) | |
| 363A00000X Physician Assistant (Licence: FL PA9104101) | |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2023-08-10 |