| NPI | 1720036890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MS 36465) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MS R861790) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2026-02-18 |