| NPI | 1689113250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MS PA00323) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MS PA00323) |
| Enumeration Date | 2017-02-15 |
| Last Update Date | 2019-02-01 |