| NPI | 1205320991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 12149108-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID O-1300) |
| 207Q00000X Family Medicine (Licence: ID MRO-1737) | |
| Enumeration Date | 2018-06-18 |
| Last Update Date | 2026-04-17 |