| NPI | 1871112805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: VA 0102206872) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0102206872) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-09 |
| Last Update Date | 2023-08-08 |