| NPI | 1619679503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: UT 14122453-1204) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: TN 6817) |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2026-06-23 |