| NPI | 1174756340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID O-0886) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MT 20300) |
| Enumeration Date | 2009-09-03 |
| Last Update Date | 2025-09-11 |