| NPI | 1144802547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102207407) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102207407) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-04-25 |
| Last Update Date | 2024-09-15 |