| NPI | 1740827724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MI 4704318470) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MI 4704318470NSA190VX) |
| Enumeration Date | 2019-12-09 |
| Last Update Date | 2022-11-10 |