| NPI | 1790304103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0101273113) |
| Additional Taxonomies | 208D00000X General Practice (Licence: VA 0101273113) |
| Enumeration Date | 2020-04-15 |
| Last Update Date | 2023-08-08 |