| NPI | 1992016083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 26607) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NE 26607) |
| Enumeration Date | 2010-06-23 |
| Last Update Date | 2022-12-16 |