| NPI | 1467811091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: WI 81125) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 1689) |
| Enumeration Date | 2016-02-10 |
| Last Update Date | 2023-07-17 |