| NPI | 1659861318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 5101025366) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 20A25129) |
| 207Q00000X Family Medicine (Licence: OH 34C.000431) | |
| 207Q00000X Family Medicine (Licence: TX W2854) | |
| Enumeration Date | 2018-05-17 |
| Last Update Date | 2026-04-30 |