| NPI | 1245204155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207ZP0102X Pathology Anatomic Pathology & Clinical Pathology (Licence: FL ME100496) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: PA MD425234) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2022-07-26 |