| NPI | 1124750807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2024-03591) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101281351) |
| Enumeration Date | 2022-06-30 |
| Last Update Date | 2025-08-06 |