| NPI | 1508512625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2023-02796) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NC 2023-02796) |
| Enumeration Date | 2022-02-28 |
| Last Update Date | 2026-06-19 |