| NPI | 1407415961 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 86705) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2019-06-10 |
| Last Update Date | 2026-04-20 |