| NPI | 1700230554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL OS20468) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC MDO.93944) |
| Enumeration Date | 2016-04-18 |
| Last Update Date | 2025-10-18 |