| NPI | 1205527306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: MO 2024046199) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-05-18 |
| Last Update Date | 2025-04-25 |