| NPI | 1629715610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CO 0073314) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-05-19 |
| Last Update Date | 2025-09-30 |