| NPI | 1174225148 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101258238) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2025-03-10 |