| NPI | 1669093233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12504) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-05-05 |
| Last Update Date | 2023-11-09 |