| NPI | 1396084752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0102203951) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-02-05 |
| Last Update Date | 2025-05-21 |