| NPI | 1235714619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0102207435) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider (Licence: VA 0102207435) | |
| Enumeration Date | 2021-03-16 |
| Last Update Date | 2023-10-30 |