| NPI | 1104453034 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OK 39094) |
| Additional Taxonomies | 208D00000X General Practice (Licence: OK 39094) |
| Enumeration Date | 2020-03-23 |
| Last Update Date | 2023-08-29 |