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 |