| NPI | 1861779951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 60413) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| 363A00000X Physician Assistant (Licence: CT 7231) | |
| Enumeration Date | 2011-11-03 |
| Last Update Date | 2025-12-09 |