| NPI | 1679026678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: SD 12298) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 5101022497) |
| Enumeration Date | 2016-07-27 |
| Last Update Date | 2022-04-04 |