| NPI | 1235802182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4301514355) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 4301514355) |
| Enumeration Date | 2021-07-27 |
| Last Update Date | 2025-07-01 |