| NPI | 1255025045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2026032038) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE 2953) |
| Enumeration Date | 2023-06-06 |
| Last Update Date | 2026-08-10 |