| NPI | 1659806255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 76086) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2020035162) |
| Enumeration Date | 2017-04-21 |
| Last Update Date | 2021-10-19 |