| NPI | 1598732760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 040163) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2006-03-07 |
| Last Update Date | 2020-08-05 |