| NPI | 1043895345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2022046237) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-03-17 |
| Last Update Date | 2024-07-18 |