| NPI | 1447696075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 28464) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 28464) |
| 207Q00000X Family Medicine (Licence: IL 125.062750) | |
| Enumeration Date | 2013-05-22 |
| Last Update Date | 2023-08-17 |