| NPI | 1629661541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: WI 81049-21) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: WI 81049-21) |
| Enumeration Date | 2021-02-12 |
| Last Update Date | 2023-08-09 |