| NPI | 1255073284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: CO 0072144) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-04-11 |
| Last Update Date | 2023-10-31 |