| NPI | 1730155177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME 103206) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4301084617) |
| Enumeration Date | 2006-02-26 |
| Last Update Date | 2024-08-05 |