| NPI | 1164952420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID O-1174) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MRO-1661) |
| Enumeration Date | 2017-06-19 |
| Last Update Date | 2025-08-18 |