| NPI | 1801270392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 82361-20) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 207Q00000X Family Medicine (Licence: IN 01077779A) | |
| Enumeration Date | 2015-07-14 |
| Last Update Date | 2023-06-27 |