| NPI | 1679924344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 39563) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NC 2018-01199) |
| 171000000X Military Health Care Provider | |
| 208600000X Surgery (Licence: SC LL39563) | |
| 208600000X Surgery (Licence: NC 2018-01199) | |
| Enumeration Date | 2016-06-23 |
| Last Update Date | 2026-01-14 |