| NPI | 1831688084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: VA 0101267940) |
| Additional Taxonomies | 208D00000X General Practice (Licence: CA A193407) |
| 208D00000X General Practice (Licence: OH 35.150161) | |
| 208D00000X General Practice (Licence: AR E-17506) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-05-03 |
| Last Update Date | 2024-03-23 |