| NPI | 1679929541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WA MD60884493) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ND 22953) |
| Enumeration Date | 2016-05-10 |
| Last Update Date | 2025-11-13 |