| NPI | 1457086233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-01364) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA R12374) |
| Enumeration Date | 2022-07-18 |
| Last Update Date | 2025-08-22 |