| NPI | 1114346129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM DO2022-0050) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2015-01973) |
| Enumeration Date | 2014-04-08 |
| Last Update Date | 2022-06-06 |