| NPI | 1235714619 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102207435) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0102207435) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-16 |
| Last Update Date | 2025-05-03 |