| NPI | 1922629252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2021-02482) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NC 2021-02482) |
| 208D00000X General Practice (Licence: NC 2021-02482) | |
| Enumeration Date | 2020-04-28 |
| Last Update Date | 2025-04-30 |