| NPI | 1588300958 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-02900) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AR E-18291) |
| 207Q00000X Family Medicine (Licence: VA 0102209460) | |
| Enumeration Date | 2022-05-09 |
| Last Update Date | 2025-11-19 |