| NPI | 1710014477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207QG0300X Family Medicine, Geriatric Medicine (Licence: SD 1151) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NE 866) |
| Enumeration Date | 2007-02-28 |
| Last Update Date | 2026-01-06 |