| NPI | 1346403144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP60197514) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: WA OP60197514) |
| Enumeration Date | 2008-07-02 |
| Last Update Date | 2026-06-24 |