| NPI | 1174084636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: TX S7650) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX S7650) |
| Enumeration Date | 2019-03-27 |
| Last Update Date | 2023-08-24 |