| NPI | 1164621173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 74440-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VT 042.0012016) |
| 207Q00000X Family Medicine (Licence: UT 9398214-1205) | |
| 207Q00000X Family Medicine (Licence: AK 7456) | |
| Enumeration Date | 2007-07-11 |
| Last Update Date | 2024-04-15 |