| NPI | 1457302804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2000-00509) |
| Additional Taxonomies | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: NC 200000509) |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2025-03-13 |