| NPI | 1215988019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: MI 5101016615) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101016615) |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2020-04-14 |