| NPI | 1215511480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MS 34137) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 2776) |
| Enumeration Date | 2021-05-12 |
| Last Update Date | 2025-08-27 |