| NPI | 1699166850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 261QM1102X Clinic/Center, Military Outpatient Operational (Transportable) Component |
| Enumeration Date | 2015-02-10 |
| Last Update Date | 2024-02-08 |