| NPI | 1700535861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-01455) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL87625) |
| Enumeration Date | 2022-03-23 |
| Last Update Date | 2025-07-07 |