| NPI | 1043567407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS20770) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 1141) |
| 207Q00000X Family Medicine (Licence: NE 1141) | |
| Enumeration Date | 2012-08-04 |
| Last Update Date | 2024-05-30 |