| NPI | 1891772091 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: OH 34005846) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 34-00-5846) |
| Enumeration Date | 2005-12-28 |
| Last Update Date | 2020-08-05 |