| NPI | 1760111074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID M-17718) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: ID MRM-2173) |
| Enumeration Date | 2022-06-10 |
| Last Update Date | 2025-06-13 |