| NPI | 1679193056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0102206811) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102206811) |
| Enumeration Date | 2020-04-25 |
| Last Update Date | 2023-06-21 |