NPI | 1275152811 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207R00000X Internal Medicine (Licence: VA 0102206732) |
Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102206732) |
208D00000X General Practice (Licence: VA 0102206732) | |
Enumeration Date | 2020-04-14 |
Last Update Date | 2025-06-30 |