| NPI | 1245975440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 208000000X Pediatrics (Licence: VA 0102208007) |
| Enumeration Date | 2022-05-02 |
| Last Update Date | 2025-08-29 |