| NPI | 1164419560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2024-0859) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: OK 17199) |
| 207Q00000X Family Medicine (Licence: OK 17199) | |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2026-02-02 |