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