| NPI | 1518052273 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NY 190446) |
| Additional Taxonomies | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: NY 190446) |
| 207Q00000X Family Medicine (Licence: NY 190446) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2025-07-23 |