| NPI | 1104866672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2006009612) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 0445752) |
| Enumeration Date | 2006-06-06 |
| Last Update Date | 2025-12-03 |