| NPI | 1083935951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: GA 65890) |
| Additional Taxonomies | 208D00000X General Practice (Licence: GA 65890) |
| 171000000X Military Health Care Provider (Licence: GA 65890) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-06-15 |
| Last Update Date | 2021-09-13 |