| NPI | 1720157555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NV 29544) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 181302-1205) |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2026-08-05 |