| NPI | 1366020760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61167274) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WI 86401-20) |
| Enumeration Date | 2021-03-29 |
| Last Update Date | 2025-10-06 |