| NPI | 1083460901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: WI 82023-21) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: WI 82023-21) |
| Enumeration Date | 2024-04-30 |
| Last Update Date | 2026-02-13 |