| NPI | 1144920893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101283177) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-03-09 |
| Last Update Date | 2024-07-13 |