| NPI | 1306837596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: TX F8663) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101024143) |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2007-07-08 |