| NPI | 1043283583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 040654) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2021-08-02 |