| NPI | 1063494599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61602678) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NH 10535) |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2026-04-22 |