| NPI | 1356917603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 93792) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: GA 93792) |
| Enumeration Date | 2021-05-27 |
| Last Update Date | 2026-01-26 |