| NPI | 1558774257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: VA 0102204347) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0116026881) |
| Enumeration Date | 2014-06-10 |
| Last Update Date | 2025-08-13 |