| NPI | 1932736998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: HI DOS-2570-0) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 208D00000X General Practice (Licence: NC 2021-02706) | |
| Enumeration Date | 2020-03-26 |
| Last Update Date | 2025-08-27 |