| NPI | 1184032146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101279990) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 183500000X Pharmacist (Licence: NY 059388) | |
| Enumeration Date | 2014-07-23 |
| Last Update Date | 2023-12-19 |