| NPI | 1154987683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102207132) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA OL60965167) |
| Enumeration Date | 2019-05-09 |
| Last Update Date | 2026-08-18 |