| NPI | 1760478044 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2001-00698) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NC 200100698) |
| Enumeration Date | 2005-09-22 |
| Last Update Date | 2018-04-12 |