| NPI | 1508912304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS-5589) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA 01335) |
| 207Q00000X Family Medicine (Licence: MO R5860) | |
| Enumeration Date | 2007-01-25 |
| Last Update Date | 2025-09-28 |