| NPI | 1306545801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: NE 36568) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-02-23 |
| Last Update Date | 2025-07-09 |