| NPI | 1356095574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0102208199) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 171000000X Military Health Care Provider (Licence: VA 0102208199) | |
| Enumeration Date | 2022-02-07 |
| Last Update Date | 2024-07-15 |