| NPI | 1760999130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 2018014707) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2017033425) |
| Enumeration Date | 2018-01-06 |
| Last Update Date | 2019-02-22 |