| NPI | 1629647805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101028098) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NE TEP9071) |
| Enumeration Date | 2021-06-22 |
| Last Update Date | 2024-10-11 |