| NPI | 1538148762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101266057) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: FL ME141359) |
| 207QS0010X Family Medicine Sports Medicine (Licence: FL ME141359) | |
| Enumeration Date | 2006-01-16 |
| Last Update Date | 2024-02-10 |