| NPI | 1609139708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 9700A) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2012-06-22 |
| Last Update Date | 2023-11-27 |