| NPI | 1295475069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MI 5101027782) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-03-30 |
| Last Update Date | 2024-03-11 |