| NPI | 1518539964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD61541896) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4351048433) |
| Enumeration Date | 2021-07-14 |
| Last Update Date | 2025-02-13 |