| NPI | 1083095061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA IMLC.MD.70005245) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125067597) |
| 207Q00000X Family Medicine (Licence: TX R6125) | |
| Enumeration Date | 2015-06-15 |
| Last Update Date | 2026-04-08 |