| NPI | 1619664505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: HI DOSR-617) |
| Enumeration Date | 2023-04-20 |
| Last Update Date | 2024-02-20 |