| NPI | 1053964544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2019030578) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2014004848) |
| Enumeration Date | 2019-07-23 |
| Last Update Date | 2025-04-16 |