| NPI | 1265892426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 89976) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 1682) |
| Enumeration Date | 2016-03-02 |
| Last Update Date | 2023-08-23 |