| NPI | 1215636733 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CO DR.0074101) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX BBP10086035) |
| 171000000X Military Health Care Provider (Licence: CO DR.0074101) | |
| Enumeration Date | 2023-02-23 |
| Last Update Date | 2024-12-02 |