| NPI | 1124723846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 010220889) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: VA 0102208899) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2023-04-03 |
| Last Update Date | 2026-07-01 |