| NPI | 1205931565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 40895) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN 56262) |
| 207Q00000X Family Medicine (Licence: ME MD21033) | |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2026-07-06 |