NPI | 1275152811 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102206732) |
Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
208D00000X General Practice (Licence: VA 0102206732) | |
Enumeration Date | 2020-04-14 |
Last Update Date | 2023-08-18 |