| NPI | 1780927954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 1710I1003X Military Health Care Provider, Independent Duty Medical Technicians |
| Enumeration Date | 2013-04-05 |
| Last Update Date | 2019-10-04 |