| NPI | 1164080560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KS 04-46532) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R-11576) |
| Enumeration Date | 2019-05-31 |
| Last Update Date | 2022-11-28 |