| NPI | 1407948458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MN 108778) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2023-03-16 |