| NPI | 1790313567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: VA 0101273053) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2020-03-29 |
| Last Update Date | 2023-10-02 |