| NPI | 1376003392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2022-02703) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN 61968) |
| 207Q00000X Family Medicine (Licence: VA 0101273210) | |
| Enumeration Date | 2019-03-25 |
| Last Update Date | 2025-01-08 |