| NPI | 1720367055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101022331) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MI 5101022331) |
| Enumeration Date | 2011-08-04 |
| Last Update Date | 2019-10-15 |