| NPI | 1811331846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207ZP0102X Pathology, Anatomic Pathology & Clinical Pathology (Licence: CO DR.0065469) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 1259) |
| 208D00000X General Practice (Licence: NE 1259) | |
| Enumeration Date | 2013-04-21 |
| Last Update Date | 2021-02-10 |