| NPI | 1104313683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101268158) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 207Q00000X) |
| Enumeration Date | 2018-04-19 |
| Last Update Date | 2021-03-22 |