| NPI | 1649295866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60568380) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301074411) |
| 207Q00000X Family Medicine (Licence: ID M-12956) | |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2026-07-27 |