| NPI | 1770873531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: NM DO2024-0079) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: WY 9992a) |
| Enumeration Date | 2011-04-13 |
| Last Update Date | 2024-06-13 |