| NPI | 1770333858 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2083P0011X Preventive Medicine, Undersea and Hyperbaric Medicine (Licence: VA 0102209591) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102209591) |
| 208D00000X General Practice (Licence: VA 0102209591) | |
| Enumeration Date | 2024-03-25 |
| Last Update Date | 2026-04-21 |