| NPI | 1497384457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM DO2023-1034) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 58.031299) |
| Enumeration Date | 2020-04-02 |
| Last Update Date | 2025-09-03 |