| NPI | 1164015442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: VA 0101276156) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101276156) |
| Enumeration Date | 2021-02-17 |
| Last Update Date | 2025-07-25 |