| NPI | 1376006890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2022029081) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OK 7126) |
| Enumeration Date | 2019-04-11 |
| Last Update Date | 2026-10-14 |