| NPI | 1790043248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 61853) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2012-05-02 |
| Last Update Date | 2024-04-10 |