| NPI | 1215970504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MT MED-PHYS-LIC-11607) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: LA 09902R) |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2024-12-09 |