| NPI | 1215504105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0116035308) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-06-08 |
| Last Update Date | 2021-06-24 |