| NPI | 1215931936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SC 21465) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 9901642) |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2025-11-05 |