| NPI | 1215275110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: OH 34.014640) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102203955) |
| 171000000X Military Health Care Provider (Licence: TX R4411) | |
| 208D00000X General Practice (Licence: VA 0102203955) | |
| 208D00000X General Practice (Licence: TX R4411) | |
| Enumeration Date | 2013-01-28 |
| Last Update Date | 2021-01-22 |