| NPI | 1679140800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101284810) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-06-07 |
| Last Update Date | 2025-02-14 |