| NPI | 1104323468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: IN 02005757A) |
| Additional Taxonomies | 208D00000X General Practice (Licence: TX V6287) |
| Enumeration Date | 2018-04-12 |
| Last Update Date | 2025-05-19 |