| NPI | 1538626460 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102206290) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 171000000X Military Health Care Provider (Licence: VA 0102206290) | |
| Enumeration Date | 2019-02-27 |
| Last Update Date | 2024-03-28 |