| NPI | 1952759607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CA 20A15762) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: CA 20A15762) |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2018-04-10 |