| NPI | 1629069695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207V00000X Obstetrics & Gynecology (Licence: UT 6901969-1205) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: OR 35075241) |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2019-05-31 |