| NPI | 1124092689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL 00027188) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 2083A0100X Preventive Medicine, Aerospace Medicine (Licence: AL 27188) | |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2021-08-25 |