| NPI | 1104455609 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 76397-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 8730-851) |
| Enumeration Date | 2020-04-06 |
| Last Update Date | 2024-11-20 |