| NPI | 1255033833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101283854) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-03-20 |
| Last Update Date | 2025-11-06 |