| NPI | 1316694714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101281161) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0116036929) |
| Enumeration Date | 2022-03-05 |
| Last Update Date | 2024-02-18 |