| NPI | 1639674328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102205793) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 171100000X Acupuncturist (Licence: VA 0102205793) | |
| Enumeration Date | 2018-03-26 |
| Last Update Date | 2021-09-26 |