| NPI | 1508422767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA OP61296297) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: OH 58031022) |
| Enumeration Date | 2019-05-14 |
| Last Update Date | 2022-11-30 |