| NPI | 1558706051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101257961) |
| Enumeration Date | 2013-05-10 |
| Last Update Date | 2023-06-20 |