| NPI | 1679193536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 15703A) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NV DO3229) |
| Enumeration Date | 2020-04-21 |
| Last Update Date | 2024-02-02 |