| NPI | 1598359713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0101276029) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101276029) |
| Enumeration Date | 2021-02-28 |
| Last Update Date | 2026-03-02 |