| NPI | 1629579263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101267508) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101267508) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-02-27 |
| Last Update Date | 2023-08-13 |