| NPI | 1356753453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2026-01580) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NH 20559) |
| Enumeration Date | 2014-05-22 |
| Last Update Date | 2026-06-05 |