| NPI | 1760956387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001015267) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: AZ 7529) |
| 363A00000X Physician Assistant (Licence: AZ 7529) | |
| Enumeration Date | 2019-01-16 |
| Last Update Date | 2025-08-26 |