| NPI | 1194022566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: MI 4301084915) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: PR 9502) |
| Enumeration Date | 2011-02-22 |
| Last Update Date | 2011-02-22 |