| NPI | 1043603863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA A147045) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2015-03-18 |
| Last Update Date | 2024-12-11 |