| NPI | 1386056992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: LA 333104) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2017-00843) |
| 207Q00000X Family Medicine (Licence: NC 201679) | |
| Enumeration Date | 2014-05-30 |
| Last Update Date | 2024-01-02 |