| NPI | 1740663103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: VA 0101260823) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2015-07-02 |
| Last Update Date | 2026-07-20 |