| NPI | 1043415987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 6016A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 6016-A) |
| Enumeration Date | 2007-06-20 |
| Last Update Date | 2025-07-31 |