| NPI | 1083790745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: CA G59935) |
| Additional Taxonomies | 174400000X Specialist (Licence: CA G59935) |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2007-07-08 |