| NPI | 1063933158 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QP2300X Clinic/Center, Primary Care (Licence: PR 19700) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: PR 19700) |
| Enumeration Date | 2017-06-29 |
| Last Update Date | 2023-05-12 |