| NPI | 1376220160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2026030911) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.082109) |
| Enumeration Date | 2023-07-03 |
| Last Update Date | 2026-07-15 |