| NPI | 1003496720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 92561) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC BLOU-LA8994) |
| Enumeration Date | 2021-04-08 |
| Last Update Date | 2024-08-23 |