| NPI | 1760845739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WY 12478A) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 147-T2) |
| Enumeration Date | 2016-03-29 |
| Last Update Date | 2021-09-24 |