| NPI | 1073008025 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 101708-875)  | 
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.073287)  | 
| Enumeration Date | 2018-06-22 | 
| Last Update Date | 2024-08-08 |