| NPI | 1629710157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA 54186) |
| Additional Taxonomies | 208D00000X General Practice (Licence: SC 93144) |
| Enumeration Date | 2022-04-13 |
| Last Update Date | 2025-07-15 |