| NPI | 1730826900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL ME173109) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: IL 125.079765) |
| Enumeration Date | 2022-05-18 |
| Last Update Date | 2025-10-28 |