| NPI | 1578256244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: NC 2024-02966) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-05-30 |
| Last Update Date | 2025-01-30 |