| NPI | 1134796378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT 139077) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5151014941) |
| Enumeration Date | 2021-06-07 |
| Last Update Date | 2025-04-09 |