| NPI | 1285861393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NC 2010-01706) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2010-01706) |
| Enumeration Date | 2009-06-16 |
| Last Update Date | 2019-02-26 |