| NPI | 1548607815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: PA OS017210) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 207Q00000X Family Medicine (Licence: PA OT015107) | |
| 207R00000X Internal Medicine (Licence: PA OS017210) | |
| Enumeration Date | 2013-05-28 |
| Last Update Date | 2023-08-29 |