| NPI | 1700997459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 3792A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2010028272) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2026-07-10 |