| NPI | 1013994342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL DO630) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KY 02709) |
| Enumeration Date | 2005-12-28 |
| Last Update Date | 2026-08-25 |