| NPI | 1104276872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QA0401X Family Medicine, Addiction Medicine (Licence: MI 5101022526) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101022526) |
| Enumeration Date | 2016-06-14 |
| Last Update Date | 2026-05-14 |