| NPI | 1225595531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: VA 0101270203) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0116032991) |
| 171000000X Military Health Care Provider (Licence: SC 86705) | |
| 208D00000X General Practice (Licence: SC 86705) | |
| Enumeration Date | 2019-02-22 |
| Last Update Date | 2023-06-26 |