| NPI | 1164415113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0101280408) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ 18138) |
| Enumeration Date | 2005-08-24 |
| Last Update Date | 2025-12-22 |