| NPI | 1902592009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: NC 2025-00251) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-04-12 |
| Last Update Date | 2025-05-07 |