| NPI | 1700360047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MS PA00437) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-09-22 |
| Last Update Date | 2024-10-14 |