| NPI | 1164738159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS11511) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL UO2557) |
| Enumeration Date | 2010-08-27 |
| Last Update Date | 2026-01-07 |