| NPI | 1588676456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: TN 0000031773) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101251024) |
| Enumeration Date | 2006-08-12 |
| Last Update Date | 2026-01-06 |