| NPI | 1902437700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: HI MDR-8552) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: HI MDR-8552-0) |
| Enumeration Date | 2020-01-30 |
| Last Update Date | 2025-07-03 |