| NPI | 1780487090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1236769) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: OR 1236769) |
| Enumeration Date | 2025-03-31 |
| Last Update Date | 2026-01-09 |