| NPI | 1710417829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 12912A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: KS 94-09297) |
| Enumeration Date | 2017-06-13 |
| Last Update Date | 2022-11-15 |