| NPI | 1164900080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: GA 86604) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: GA 86604) |
| Enumeration Date | 2018-08-02 |
| Last Update Date | 2024-03-05 |