| NPI | 1639924889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0102209606) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 171000000X Military Health Care Provider (Licence: VA 0102209606) | |
| Enumeration Date | 2024-04-22 |
| Last Update Date | 2025-08-24 |