| NPI | 1891315925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0101273125) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 261QM1100X Clinic/Center, MilitaryU.S. Coast Guard Outpatient | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-18 |
| Last Update Date | 2024-03-11 |