| NPI | 1255088639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0101283971) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: VA 0101283971) |
| Enumeration Date | 2022-03-07 |
| Last Update Date | 2026-06-24 |