| NPI | 1770993875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: FL 151791) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: NE 28839) | |
| Enumeration Date | 2014-04-29 |
| Last Update Date | 2022-07-07 |