| NPI | 1083102792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 74441-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.071722) |
| Enumeration Date | 2018-04-27 |
| Last Update Date | 2021-07-07 |