| NPI | 1245678838 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CA A132084) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA A132084) |
| Enumeration Date | 2013-06-05 |
| Last Update Date | 2023-04-12 |