NPI | 1821356114 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA17558) |
Additional Taxonomies | 261QM1102X Clinic/Center, Military Outpatient Operational (Transportable) Component (Licence: FL PA9116542) |
363A00000X Physician Assistant (Licence: FL PA9116542) | |
Enumeration Date | 2012-04-25 |
Last Update Date | 2025-08-14 |