| NPI | 1043830193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 208D00000X General Practice (Licence: NC 2021-03058) |
| Enumeration Date | 2020-04-18 |
| Last Update Date | 2026-08-20 |