| NPI | 1316178189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2025012600) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OR MD156341) |
| Enumeration Date | 2009-07-28 |
| Last Update Date | 2025-05-08 |