| NPI | 1902243876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: GA 81145) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: PA md460001) |
| Enumeration Date | 2013-05-31 |
| Last Update Date | 2021-12-21 |