| NPI | 1073992947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS15215) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL TRN 21215) |
| 207QA0505X Family Medicine, Adult Medicine (Licence: FL ME133438) | |
| Enumeration Date | 2015-05-26 |
| Last Update Date | 2026-02-20 |