| NPI | 1407055569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2086S0129X (Licence: WA 60949016) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 2086S0129X (Licence: NE 24962) | |
| Enumeration Date | 2007-07-17 |
| Last Update Date | 2025-04-17 |