| NPI | 1366892986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2021037529) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 94-09064) |
| 207Q00000X Family Medicine (Licence: WI 15762) | |
| Enumeration Date | 2016-06-14 |
| Last Update Date | 2026-10-05 |