| NPI | 1972166890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171000000X Military Health Care Provider (Licence: NE 32753) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NE 32753) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-04-16 |
| Last Update Date | 2023-10-12 |