| NPI | 1619460011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-00288) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 207Q00000X Family Medicine (Licence: VA 0102205870) | |
| Enumeration Date | 2018-06-11 |
| Last Update Date | 2025-06-05 |