| NPI | 1336726835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101276734) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101276734) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-29 |
| Last Update Date | 2023-06-21 |