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 |