| NPI | 1083148423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 51162) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 86216) |
| Enumeration Date | 2017-04-12 |
| Last Update Date | 2026-06-18 |