| NPI | 1720612955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: VA 0102206863) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0102206863) |
| 171000000X Military Health Care Provider | |
| Enumeration Date | 2020-02-26 |
| Last Update Date | 2026-07-29 |