| NPI | 1568081495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: GA 90252) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: GA 90252) |
| Enumeration Date | 2020-04-10 |
| Last Update Date | 2025-02-25 |