| NPI | 1871047639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman (Licence: TX 23588888) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: NC 23588888) | |
| Enumeration Date | 2016-08-10 |
| Last Update Date | 2026-03-11 |