| NPI | 1063098473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 81393) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R-12046) |
| Enumeration Date | 2021-03-24 |
| Last Update Date | 2024-07-12 |