| NPI | 1013603109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX V3887) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX V3887) |
| Enumeration Date | 2023-04-12 |
| Last Update Date | 2024-12-18 |