| NPI | 1063560183 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: VA 0101240248) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101240248) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2013-09-23 |