| NPI | 1174215776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4351051440) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 4301514401) |
| Enumeration Date | 2023-05-22 |
| Last Update Date | 2025-06-26 |