| NPI | 1295729085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID M11819) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: ID M11819) |
| Enumeration Date | 2005-09-07 |
| Last Update Date | 2026-03-26 |