| NPI | 1508443110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR DO224391) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 12966808-1204) |
| Enumeration Date | 2021-03-28 |
| Last Update Date | 2025-09-22 |