| NPI | 1164861159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 04424) |
| 171000000X Military Health Care Provider (Licence: NE 1204) | |
| 207Q00000X Family Medicine (Licence: TN 3503) | |
| 2083A0100X Preventive Medicine, Aerospace Medicine (Licence: NE 1204) | |
| Enumeration Date | 2013-06-23 |
| Last Update Date | 2019-01-31 |