| NPI | 1043654254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NE 28071) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101267705) |
| Enumeration Date | 2013-04-18 |
| Last Update Date | 2026-02-20 |