| NPI | 1750362497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL 00012189) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2025-10-16 |