| NPI | 1265402598 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL 1356) |
| Additional Taxonomies | 2083A0100X Preventive Medicine, Aerospace Medicine (Licence: OH 34006795-R) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2025-05-07 |