| NPI | 1053106096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ZZ 139169) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: ZZ 139169) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 20230421123327) | |
| Enumeration Date | 2025-04-10 |
| Last Update Date | 2025-05-15 |