| NPI | 1053947515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084P0802X Psychiatry & Neurology, Addiction Psychiatry (Licence: WI 77673-21) |
| Additional Taxonomies | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: WA OP61512333) |
| 171000000X Military Health Care Provider (Licence: WI 77673-21) | |
| Enumeration Date | 2020-03-17 |
| Last Update Date | 2025-12-15 |