| NPI | 1457558751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: MO PT01648) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MO AT00007) |
| Enumeration Date | 2007-06-29 |
| Last Update Date | 2007-07-09 |