| NPI | 1871120360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 82016-21) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: WI 82016-21) |
| Enumeration Date | 2020-03-24 |
| Last Update Date | 2025-10-16 |