| NPI | 1740660414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NC 2019-00872) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101263777) |
| Enumeration Date | 2015-06-08 |
| Last Update Date | 2026-01-06 |