| NPI | 1164409173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD29141) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 23092) |
| Enumeration Date | 2005-12-30 |
| Last Update Date | 2010-06-29 |