| NPI | 1659351690 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: SC 20979) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: SC 20979) |
| 207Q00000X Family Medicine (Licence: SC 20979) | |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2021-04-12 |