| NPI | 1144889841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 3021556) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA7429) |
| Enumeration Date | 2019-06-07 |
| Last Update Date | 2026-05-28 |