| NPI | 1639887730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13457) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-11-08 |
| Last Update Date | 2023-08-10 |