NPI | 1023502051 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2024-0018M) |
Additional Taxonomies | 207Q00000X Family Medicine (Licence: MT MED-PHYS-LIC-101269) |
Enumeration Date | 2018-06-22 |
Last Update Date | 2025-01-27 |