| NPI | 1770113482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 35886) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-01-22 |
| Last Update Date | 2025-07-30 |