| NPI | 1851571491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KS 05-32868) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2007-11-12 |
| Last Update Date | 2021-09-08 |