| NPI | 1386324473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ na) |
| Enumeration Date | 2023-07-24 |
| Last Update Date | 2024-06-25 |