| NPI | 1245658475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS19348) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 65084-21) |
| Enumeration Date | 2014-04-04 |
| Last Update Date | 2022-12-15 |