| NPI | 1093200123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TN 65198) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA 326218) |
| Enumeration Date | 2018-07-01 |
| Last Update Date | 2022-09-06 |