| NPI | 1053312249 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: PA MD-051174-L) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MD-051174-L) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2010-02-08 |