| NPI | 1154618650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AZ 77620) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WV 30287) |
| 207Q00000X Family Medicine (Licence: OR MD165962) | |
| 207Q00000X Family Medicine (Licence: FL ME178888) | |
| Enumeration Date | 2011-07-05 |
| Last Update Date | 2026-05-04 |