| NPI | 1639582620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: GA 75053) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2014-06-06 |
| Last Update Date | 2021-11-30 |