| NPI | 1336883040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5151015468) |
| Additional Taxonomies | 208D00000X General Practice (Licence: MI 5101028101) |
| Enumeration Date | 2022-04-27 |
| Last Update Date | 2025-06-19 |