| NPI | 1801580881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101284623) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: TX BP10083655) |
| Enumeration Date | 2023-06-05 |
| Last Update Date | 2025-04-10 |