| NPI | 1689553505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QA0505X Family Medicine, Adult Medicine (Licence: FL 9120618) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9120618) |
| Enumeration Date | 2025-08-27 |
| Last Update Date | 2025-09-12 |