| NPI | 1720602824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2023-03119) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-06-04 |
| Last Update Date | 2025-02-07 |