| NPI | 1124768718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: TX U7396) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: TX U7396) | |
| Enumeration Date | 2022-03-31 |
| Last Update Date | 2025-06-05 |