| NPI | 1679711691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2009-01-29 |
| Last Update Date | 2013-07-17 |