| NPI | 1346979523 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102208347) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 261QP2300X Clinic/Center, Primary Care | |
| Enumeration Date | 2022-06-06 |
| Last Update Date | 2023-12-10 |