| NPI | 1952350431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP60369961) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2016-01-26 |