| NPI | 1144382110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QV0200X Clinic/Center, VA (Licence: PR 12851) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: PR 12851) |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2015-05-12 |