| NPI | 1144788621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2083A0100X Preventive Medicine Aerospace Medicine (Licence: OH 35.140073) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: OH 35.140073) |
| 208D00000X General Practice (Licence: OH 35.140073) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-04 |
| Last Update Date | 2023-08-07 |