| NPI | 1235586611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208VP0014X Pain Medicine, Interventional Pain Medicine (Licence: WA MD70071214) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2016-05-16 |
| Last Update Date | 2026-08-11 |