| NPI | 1740675040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 69375-20) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: UT 10094314-1205) |
| Enumeration Date | 2015-04-02 |
| Last Update Date | 2021-08-10 |