| NPI | 1275913790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2018024300) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ R75126) |
| Enumeration Date | 2015-06-01 |
| Last Update Date | 2020-11-16 |