| NPI | 1497245765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101267732) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider (Licence: VA 0101267732) | |
| Enumeration Date | 2018-05-13 |
| Last Update Date | 2023-08-14 |