| NPI | 1760131841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ID O1960) |
| Additional Taxonomies | 208D00000X General Practice (Licence: ID O-1960) |
| Enumeration Date | 2022-03-23 |
| Last Update Date | 2026-07-22 |