| NPI | 1720729890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2025-02745) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: SC LL87757) |
| Enumeration Date | 2022-04-05 |
| Last Update Date | 2025-11-21 |