| NPI | 1821356114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9116542) |
| Additional Taxonomies | 261QM1102X Clinic/Center, Military Outpatient Operational (Transportable) Component (Licence: FL PA9116542) |
| Enumeration Date | 2012-04-25 |
| Last Update Date | 2023-07-10 |