| NPI | 1104879295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KS 0526609) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2021042797) |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2022-01-20 |