| NPI | 1023571783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME165268) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TX BP10066657) |
| Enumeration Date | 2019-04-10 |
| Last Update Date | 2026-04-24 |