| NPI | 1255979613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207R00000X Internal Medicine (Licence: NC 304804) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2019041114) |
| Enumeration Date | 2019-12-17 |
| Last Update Date | 2023-04-08 |