| 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 |