| NPI | 1053821710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2017024107) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MO 2017024107) |
| 363A00000X Physician Assistant (Licence: MO 2017024107) | |
| Enumeration Date | 2017-10-09 |
| Last Update Date | 2021-02-15 |