| NPI | 1306429386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CO DR.0069131) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CO DR.0069131) |
| Enumeration Date | 2021-04-28 |
| Last Update Date | 2024-03-06 |