| NPI | 1932461282 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 27494) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 27494) |
| Enumeration Date | 2012-06-12 |
| Last Update Date | 2022-06-29 |