| NPI | 1174063036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID O-1392) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101023057) |
| Enumeration Date | 2017-02-27 |
| Last Update Date | 2023-05-09 |