| NPI | 1699414763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0102208264) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0116037098) |
| Enumeration Date | 2022-05-27 |
| Last Update Date | 2026-06-08 |