| NPI | 1356915839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ACN1588) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: PR 16427-I) |
| 363A00000X Physician Assistant (Licence: PR 000964-PA) | |
| Enumeration Date | 2021-05-18 |
| Last Update Date | 2023-11-22 |