| NPI | 1073203659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: VA 0101283383) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101283383) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2023-05-09 |
| Last Update Date | 2026-07-24 |