NPI | 1124317417 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID O-1760) |
Additional Taxonomies | 171000000X Military Health Care Provider (Licence: ID O-1760) |
Enumeration Date | 2011-04-07 |
Last Update Date | 2023-04-13 |