| NPI | 1700310711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-00636) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IA MD47631) |
| Enumeration Date | 2017-04-17 |
| Last Update Date | 2025-04-23 |