| NPI | 1679154983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084P0800X Psychiatry & Neurology, Psychiatry (Licence: VA 0102208328) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102208328) |
| Enumeration Date | 2021-04-19 |
| Last Update Date | 2026-09-18 |