| NPI | 1760944607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA PA62982) |
| 363AM0700X Physician Assistant, Medical (Licence: CA PA62982) | |
| Enumeration Date | 2019-04-01 |
| Last Update Date | 2025-02-25 |