| NPI | 1831710631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IL 036.175690) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 207Q00000X Family Medicine (Licence: NE 35977) | |
| 208D00000X General Practice (Licence: NE 35977) | |
| 208D00000X General Practice (Licence: IL 036.175690) | |
| Enumeration Date | 2020-05-03 |
| Last Update Date | 2025-07-02 |