| NPI | 1104805183 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207L00000X Anesthesiology (Licence: MT 99685) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101231034) |
| Enumeration Date | 2006-01-10 |
| Last Update Date | 2021-09-28 |