| NPI | 1588319891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: CO DR.0072097) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-02-15 |
| Last Update Date | 2024-01-29 |