| NPI | 1902267099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: VA 0101263065) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101263065) |
| Enumeration Date | 2016-03-16 |
| Last Update Date | 2025-04-03 |