| NPI | 1104205368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084N0400X Psychiatry & Neurology, Neurology (Licence: UT 13139587-1204) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2015-05-21 |
| Last Update Date | 2023-03-16 |