| NPI | 1578258661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL MD.54187) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL89695) |
| Enumeration Date | 2023-04-06 |
| Last Update Date | 2026-08-24 |