| NPI | 1316674666 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2083A0100X Preventive Medicine, Aerospace Medicine (Licence: VA 0102208815) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-08-05 |
| Last Update Date | 2026-10-16 |