| NPI | 1265920789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 81388-21) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WA OP61177677) |
| Enumeration Date | 2018-04-30 |
| Last Update Date | 2025-01-09 |