| NPI | 1932838778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 2970) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2022-06-07 |
| Last Update Date | 2025-07-17 |