| NPI | 1679047195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0102208608) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 208D00000X General Practice (Licence: VA 0102208608) | |
| Enumeration Date | 2019-01-17 |
| Last Update Date | 2026-04-25 |