| NPI | 1609298017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101258728) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101258728) |
| Enumeration Date | 2014-01-21 |
| Last Update Date | 2024-12-10 |