| NPI | 1619460011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102205870) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-06-11 |
| Last Update Date | 2022-05-18 |