| NPI | 1568084150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: CT 79070) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301510053) |
| 207Q00000X Family Medicine (Licence: TX U6458) | |
| Enumeration Date | 2020-05-18 |
| Last Update Date | 2024-08-23 |