| NPI | 1235542754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: GA 78836) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: GA 6824) |
| Enumeration Date | 2014-06-03 |
| Last Update Date | 2026-04-22 |