| NPI | 1538665542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD.MD.61669853) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MT 101180) |
| Enumeration Date | 2018-03-30 |
| Last Update Date | 2025-09-04 |