| NPI | 1558711846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM MD2019-0669) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AZ 58019) |
| Enumeration Date | 2016-06-16 |
| Last Update Date | 2021-08-16 |