| NPI | 1598259046 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102205881) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: VA 0102205881) | |
| Enumeration Date | 2018-06-19 |
| Last Update Date | 2023-08-03 |