| NPI | 1679829634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: NE NE27759) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2012-07-27 |
| Last Update Date | 2021-08-11 |