| NPI | 1588284145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102206818) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-04-23 |
| Last Update Date | 2025-09-03 |