| NPI | 1275096737 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: MT MED-PHYS-LIC-159113) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: MT 159113) |
| Enumeration Date | 2019-04-11 |
| Last Update Date | 2025-11-05 |