| NPI | 1760018857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101273352) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101273352) |
| Enumeration Date | 2020-03-20 |
| Last Update Date | 2025-04-09 |