| NPI | 1043714405 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 06038) | 
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 012205817) | 
| Enumeration Date | 2018-03-21 | 
| Last Update Date | 2025-09-09 |