| NPI | 1679926596 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 3822-23) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3822-23) |
| Enumeration Date | 2016-07-15 |
| Last Update Date | 2024-08-09 |