| NPI | 1265013445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2024-02024) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MN 72079) |
| Enumeration Date | 2021-04-19 |
| Last Update Date | 2024-07-23 |