| NPI | 1740984889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NY 330797-01) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NY 330797-01) |
| Enumeration Date | 2023-03-30 |
| Last Update Date | 2025-06-12 |