| NPI | 1134649684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NE 31110) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2017-06-26 |
| Last Update Date | 2023-03-17 |