| NPI | 1174383616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: ID 7971868) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2024-03-21 |
| Last Update Date | 2025-07-27 |