| NPI | 1053608802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60410629) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-06-30 |
| Last Update Date | 2023-06-29 |