| NPI | 1609523240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101279593) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101279593) |
| Enumeration Date | 2022-03-03 |
| Last Update Date | 2025-07-09 |