| NPI | 1962036954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208D00000X General Practice (Licence: VA 0102206829) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: VA 0102206829) |
| 171000000X Military Health Care Provider (Licence: VA 0102206829) | |
| Enumeration Date | 2020-02-27 |
| Last Update Date | 2025-09-18 |