| NPI | 1639169485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: LA 025398) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA 025398) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2021-06-08 |