| NPI | 1679047195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: FL 17145) |
| Additional Taxonomies | 208D00000X General Practice (Licence: FL 17145) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-01-17 |
| Last Update Date | 2023-10-27 |