| NPI | 1679997779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID PA-1244) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 8930965-1206) |
| Enumeration Date | 2014-02-10 |
| Last Update Date | 2022-02-07 |