| NPI | 1164710182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME138937) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 8746A) |
| 207Q00000X Family Medicine (Licence: CO CDR0000225) | |
| Enumeration Date | 2011-07-11 |
| Last Update Date | 2026-04-27 |